Earthquake-related trauma results in crush injuries and bony- and soft-tissue trauma. There are no systematic reviews analyzing the typical injury patterns and treatments in “Mega-Mass-Casualty” earthquakes. The characterization of an injury pattern specific to disaster type, be it natural or manmade, is imperative to build an effective disaster preparedness and response system.

The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search strategy was developed to identify all publications relating to earthquakes and the orthopedic treatment in adult patients. The following databases were searched: PubMed (Medline; US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), Ovid (Ovid Technologies; New York, New York USA), Web of Science (Thomson Reuters; New York, New York USA), and The Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom).

The searches identified 4,704 articles: 4,445 after duplicates were removed. The papers were screened for title and abstract and 65 out of those were selected for full-text analysis. The quality of data does not permit a standard-of-care (SOC) to be defined. Scarcity and poor quality of the data collected also may suggest a low level of accountability of the activity of the international hospital teams. Qualitatively, it is possible to define that there are more open fractures during daytime hours than at night. Excluding data about open and closed fractures, for all types of injuries, the results underline that the higher the impact of the earthquake, as measured by Richter Magnitude Scale (RMS), the higher is the number of injuries.

Regarding orthopedic injuries during earthquakes, special attention must be paid to the management of the lower limbs most frequently injured. Spinal cord involvement following spine fractures is an important issue: this underlines how a neurosurgeon on a disaster team could be an important asset during the response. Conservative treatment for fractures, when possible, should be encouraged in a disaster setting. Regarding amputation, it is important to underline how the response and the quality of health care delivered is different from one team to another. This study shows how important it is to improve, and to require, the accountability of international disaster teams in terms of type and quality of health care delivered, and to standardize the data collection.

BortolinM, MorelliI, VoskanyanA, JoyceNR, CiottoneGR. Earthquake-Related Orthopedic Injuries in Adult Population: A Systematic Review. Prehosp Disaster Med. 2017;32(2):201–208.

Four weeks after the earthquake in Kashmir, Pakistan, multi-disciplinary surgical teams were organized within the United Kingdom to help treat disaster victims who had been transferred to Rawalpindi. The work of these teams between 05-17 November 2005 is reviewed, and experiences and lessons learned are presented.

Two self-sufficient teams consisting of orthopedic, plastic surgical, anesthetic, and theatre staff were deployed consecutively over a two-week period. A trauma unit was set up in a donated ward within a private ophthalmological hospital in Rawalpindi.

Seventy-eight patients with a mean age of 23 years were treated: more than half (40) were <16 years of age. Fifty-two patients only had lower limb injuries, 18 upper limb injuries, and eight combined lower and upper limb. The most common types of injuries were: (1) tibial fractures (n = 24), with the majority being open grade 3B injuries (n = 22); (2) femoral fractures (n = 11); and (3) forearm fractures (n = 9). Almost half (n = 34) of the fractures were open injuries requiring soft tissue cover.

Over 12 days, 293 operations were performed (average 24.4 per day). A total of 202 examinations under anesthesia, washouts, and debridements were performed. The majority of wounds required multiple washouts prior to definitive procedures. Thirty-four definitive orthopedic procedures (fixations) and 57 definitive plastic procedures were performed. Definitive orthopedic procedures included 15 circular frame fixations of long bones, nine of which required acute shortening and five open reduction and internal fixation of long bones. Definitive plastic procedures included 21 skin grafts, four amputations, 11 revisions of amputations, 20 regional flaps, and one free flap.

A joint ortho-plastic approach was key to the treatment of the spectrum of injuries encountered. Only four patients required fresh amputations. Twenty patients may have required amputation without the use of ring fixators and soft tissue reconstruction. Having self-sufficient teams along with their own equipment and supplies also was mandatory in order not to put further demand on already scarce resources. However, mobilizing such teams logistically was difficult, and therefore, an organization consisting of willing volunteers for future efforts has been established.